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Sheriffs split on how to investigate jail deaths

Sheriffs have appointed their own deputies to investigate co-workers in about 40% of jail deaths, a Milwaukee Journal Sentinel analysis shows. That decision has prompted backlash in Milwaukee County after three deaths last year.

Sheriffs split on how to investigate jail deaths

An inquest has been ordered following the April 2016 dehydration death of Milwaukee County Jail inmate Terrill Thomas. Here's how an inquest works, and how the only other Milwaukee County inquest in the past decade ended.
Jacob Carpenter/Milwaukee Journal Sentinel

Milwaukee County Sheriff David A. Clarke Jr., who has opted to have his own detectives investigate three of the four deaths at his jail in 2016.(Photo: Michael McLoone / for Milwaukee Journal Sentinel)

When Milwaukee County Sheriff David A. Clarke Jr.'s staff investigated three deaths at his jail last year, the decision prompted outcry from local politicians and family members of the deceased.

But the approach is hardly unprecedented in Wisconsin, where sheriff’s detectives routinely investigate their co-workers following inmate deaths, a Milwaukee Journal Sentinel analysis shows.

Over the past five years, about 40% of deaths in Wisconsin county jails were investigated internally, without an independent agency called to lead the case, the Journal Sentinel found. In the other 60% of cases, sheriff's departments and offices requested neighboring police agencies to take over the case, often within minutes or hours of a death.

The Journal Sentinel's survey of sheriff's officials accounted for 56 of the 62 deaths of county inmates between 2012 and 2016. Officials in six counties didn't respond to requests for information. About half the 56 deaths were due to suicide and the other half resulted from medical issues.

None of the 56 death investigations has resulted in criminal charges against jail staff or inmates. Rather, the investigations more often reveal inadequate monitoring before an inmate's suicide or poor medical care before a health emergency.

Some families fear that any mistakes by jail staff could be covered up by internal investigators. Those concerns were voiced last year in Milwaukee County when Clarke requested an outside investigation into one death at his jail — inmate Terrill Thomas, who died of dehydration — but opted to keep the other three investigations in-house.

In all three of those cases, family members of the deceased said they had little to no confidence in Clarke’s office, citing the spate of deaths and his refusal to release information about the investigations. Leon Limon, whose 38-year-old sister, Kristina Fiebrink, died at the Milwaukee County Jail in August, said the Sheriff's Office hasn't contacted him once to discuss the investigation or a cause of death.

Kristina Fiebrink (left), 38, and Michael Madden, 29, died while incarcerated at the Milwaukee County Jail in August 2016 and October 2016, respectively. Both died as a result of heart issues, according to medical examiner's reports.(Photo: Courtesy of Leon Limon and Gail Stockton)

"Is the investigation going to be fair? Probably not," Limon said. "With the way Sheriff Clarke is acting, who knows?"

All four investigations remain open. Prosecutors are reviewing the deaths of Thomas and a newborn, whose mother gave birth without any jail staff noticing, for possible criminal charges. It’s unclear who would be charged in either case, although this month prosecutors indicated they may be pursuing felony charges against jail staff in the Thomas case for abuse or neglect of an inmate.

A desire for transparency

"I don't want to be accused of any cover-ups," said Monroe County Sheriff Scott Perkins, who required outside investigations after two jail deaths in the past two years.

The potential for conflicts of interest was a main reason why state legislators passed a law in 2014 requiring outside investigations into all deaths caused by law enforcement officials. That law, however, was largely targeted at officer-involved shooting deaths, and it didn't require independent investigations into jail deaths.

Officials at agencies that didn't request outside reviews of jail deaths said they're sometimes not needed, particularly when an inmate has been in poor health or commits suicide. In Ashland County, for example, sheriff’s officials opted against an outside investigation into the death of 74-year-old Eugene Bell, who died in the hospital after a lengthy illness.

Some sheriff’s officials also noted the Wisconsin Department of Corrections reviews all jail deaths for possible violations of local and state policies.

"There's already that check and balance in there," said Wood County Sheriff's Capt. Theodore Ashbeck, whose office had its own detectives investigate an inmate’s suicide in March 2016. Ashbeck fired a corrections officer as a result of the suicide, finding the officer failed to stop the inmate from hanging a sheet across the front of his cell, obscuring the view into his space.

The Department of Corrections review typically doesn’t start until months after an inmate’s death, and its staff isn’t required to re-interview all key witnesses. In one of the deaths at Perkins’ jail in Monroe County, for example, corrections staff didn’t re-interview the two inmates housed with a woman who hanged herself in a cell, according to department documents.

Scope of review varies

Among sheriff’s departments and offices that request outside investigations, the scope of the independent reviews can vary.

Many agencies request outside help immediately after a death, and leave the full investigation to independent investigators.

But in at least two counties, Outagamie and Ozaukee, local sheriff's detectives conduct the initial investigation, then turn over their findings to an outside agency for a secondary review.

In Rock County, public pressure led sheriff's officials to get an outside review of one jail death, but not another. After 38-year-old Dante Wilson died of heart failure in August 2015, sheriff's officials asked for a secondary review by Dane County investigators, who determined a nurse failed to properly treat Wilson. Eight months later, an outside investigation wasn't sought when 45-year-old Sheri Parker also died of heart failure hours after being released from a hospital.

"The only reason that somebody from the outside agency was requested was because the public was calling for it and we wanted to have complete transparency," Rock County Sheriff's Cmdr. Erik Chellevold said. "There wasn't that push from the public or the media attention to the second death."

In response to Clarke's refusal to get outside investigations in jail deaths, the Milwaukee County Board of Supervisors unanimously voted last month to support a state law requiring them in all cases. No such legislation has been introduced, but state Sen. Chris Larson (D-Milwaukee) said he's in the early stage of drafting a bill.

"It's important to make sure they're looked at with scrutiny, and you don't want to have the same people who were involved in the deaths investigating because of inherent perceptions of bias," Larson said.

Sens. Chris Larson (right) and Alberta Darling talk before the swearing in ceremony of the 103rd opening session of the Wisconsin State Senate in Madison.(Photo: Andy Manis for the Milwaukee Journal Sentinel)

Several Milwaukee-area Democratic lawmakers have called for Clarke's resignation following the deaths and his lack of communication about them. In a letter, Larson and two other lawmakers said the four families "lost their loved ones due to Clarke's gross mismanagement" — even though no investigating agency has released any findings about whether jail staff contributed to any of the deaths.

Clarke, who declined to comment for this story, has generally been dismissive of complaints about his handling of the jail deaths.

Clarke has noted that two inmates — Michael Madden, 29, and Fiebrink — died of natural causes due to heart ailments and had extensive histories of drug use. An independent court-appointed monitor found jail staff failed to properly screen Fiebrink and place her on preventative detoxification protocol, though it’s unclear whether those mistakes contributed to her death.

Clarke hasn't commented specifically about the deaths of Thomas and newborn Laliah Swayzer, whose cause of death has been listed as "undetermined" by the Milwaukee County Medical Examiner's Office.

Larson said it's too early to know whether any proposals would find support in the Republican-controlled Legislature. His bill would likely mirror the legislation enacted in 2013 to require outside investigations into officer-involved deaths.

"I think that's the easiest fix, is to use that same metric that was tried and true in getting that first piece of legislation passed," Larson said.

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Newly sworn-in Milwaukee County Sheriff David A. Clarke Jr.,acknowledges the applause of those gathered at a ceremony in the Milwaukee County Courthouse rotunda in March 2002, including his wife (second from left). Clarke was appointed to the position by Gov. Scott McCallum. Milwaukee Journal Sentinel files

Milwaukee County Sheriff David A. Clarke Jr. (left) shares a laugh with Milwaukee Police Chief Arthur Jones and other Milwaukee officers during the Third District Community Justice Center First Year Anniversary Celebration at 1953 N. 34th St. in June 2002. Clarke is only the second minority to hold the sheriff position. Milwaukee Journal Sentinel files

Milwaukee County Sheriff David A. Clarke Jr. talks with Devary Tucker, 1, during the Third District Community Justice Center First Year Anniversary Celebration in Milwaukee in June 2002. Milwaukee Journal Sentinel files

Milwaukee County Sheriff David Clarke (left) and Today's TMJ4's Contessa Brewer look over and judge the entries entered in the ugly vegetable contest in August 2002 at the Westown Farmer's Market. Milwaukee Journal Sentinel files

Milwaukee County Sheriff David Clarke Jr. is pleased with the incoming election results at his headquarters at the Park East Hotel in November 2002 during his victory over Republican challenger Ken Bohn, Franklin police chief. Milwaukee Journal Sentinel files

Milwaukee County Sheriff David Clarke Jr. is congratulated by Milwaukee Mayor John Norquist following installation ceremonies in January 2002 at the Milwaukee County Courthouse rotunda. Clarke, who was appointed Milwaukee County sheriff, was sworn in after being elected to the position this time. Milwaukee Journal Sentinel files

Sheriff David Clarke Jr. speaks during the Band Together Rally for America in March 2003 at Cathedral Square Park. The rally was held in support of the troops in Iraq and Kuwait. Milwaukee Journal Sentinel files

After visiting with Daushoned Williams and her children at their residence near N. 27 St. and North Ave., Milwaukee County Sheriff David A. Clarke Jr. continues on a tour of the neighborhood accompanied by members of the media in July 2005. Milwaukee Journal Sentinel files

Milwaukee County Sheriff David A. Clarke Jr. holds a news conference at O'Donnell Park to address issues related to the 26,000 pound piece of concrete that fell from the the parking structure there in June 2010, killing a 15-year-old boy. Milwaukee Journal Sentinel files

Milwaukee County Sheriff David Clarke Jr. answers questions after a news conference in the Milwaukee County Jail to explain his purchase of tasers for correctional officers in response to ongoing problems with them being assaulted by inmates in September 2011. Milwaukee Journal Sentinel files

"I think this budget sets us up to fail in our mission to provide a safe environment for people in Milwaukee County, in addition to the services we provide," says Milwaukee County's Sheriff David Clarke Jr. of the county executive's proposed $15-million cut to Sheriff's Department budget in October 2011. Milwaukee Journal Sentinel files

Milwaukee County Sheriff David Clarke Jr. carries a memorial wreath during a ceremony at Hi-Mount School in May 2013 for Alexis Patterson, who disappeared in 2002 when she was 7 years old while walking a 1/2 block from her home to the school. Milwaukee Journal Sentinel files

Andy Kochanski (left), owner of Concertina Beer Hall, meets with Milwaukee County Sheriff David Clarke Jr. before a concealed carry permit class. A gun rights group, Wisconsin Carry, held a free training class for those seeking concealed carry permits at Kochanski's bar, Concertina Beer Hall in Milwaukee in August 2013. Kochanski fatally shot a would-be-robber he said tried to rob the business at gunpoint. Milwaukee Journal Sentinel files

Milwaukee County Sheriff David Clarke Jr. in January 2015 blasts local officials who didn't attend a ceremony to show appreciation for law enforcement officers at the Milwaukee Professional Firefighters Hall. , Milwaukee Journal Sentinel files

Gov. Scott Walker in June 2015 signed two bills in Milwaukee at the Milwaukee County sheriff's office that expanded gun rights in Wisconsin. He was joined by Sheriff David A. Clarke Jr. and others. Milwaukee Journal Sentinel files

Milwaukee County Sheriff David Clarke Jr. greets Donald J. Trump as Trump takes the stage during a campaign stop in September 2016 at the Waukesha County Expo Center in Waukesha. Milwaukee Journal Sentinel

Reverend John W. McVicker, Sr. (left), Pastor of Christ the King Baptist Church and Milwaukee County Sheriff David A. Clarke Jr. proceed on the sidewalk on W. Garfield Avenue with a wreath in remembrance of Patterson. - ALEXIS - Family, friends, and members of the Milwaukee County Sheriffs Office gathered to mark the 15th anniversary of the disappearance of Alexis Patterson at Hi-Mount School on W. Garfield Avenue in Milwaukee. She was seven years old at the time of her disappearance, and would now be 22 years old. The Sheriffs Office is still offering a $10,000 reward for information that leads to her return. Wednesday, May 3, 2017. - Photo by Mike De Sisti / Milwaukee Journal Sentinel Mike De Sisti/Milwaukee Journal Sentinel

- LAKEFRONT - Sheriff David A. Clarke Jr. will held a news conference today to provide an update on Milwaukee County Sheriffs deputy-involved shooting at Milwaukee's lakefront Sunday evening. A man and woman remain hospitalized Monday after they were wounded by a Milwaukee County sheriff's deputy who fired into the SUV they were driving in during a pursuit on the lakefront.Monday, June 12, 2017. - Photo by Mike De Sisti / Milwaukee Journal Sentinel Mike De Sisti, Milwaukee Journal Sentinel